Transformational Leadership

East Orange General Hospital's CNO changes the culture of the facility into a place RNs want to be

By Sandy Keefe, MSN, RN

When Nelson Tuazon, MAEd, MSN, MBA, RN, CNAA, FACHE, accepted the position of senior vice president and chief nursing officer at East Orange General Hospital, East Orange, NJ, in August 2005, he faced a daunting task.

"This hospital was predicted to close because there were five other acute care hospitals in the area and it was facing financial hardships," he explained. "The nursing department was completely demoralized, with a vacancy rate of up to 40 percent on some units, and agency staff was essentially manning the floors to the tune of $3 million per year."

A Fiscal Advocate

Unfazed by the challenges before him, Tuazon rolled up his sleeves and went to work.

"This is my first nurse executive job, but I had a history as a nursing director of eliminating agency use within 6 months and knew I could do that here as well," he said. "One of the strong points I've brought to this hospital is my fiscal knowledge. The finance people don't relate to statements like 'Our units are busy' or 'Our acuity is up.' When the nurse executive can articulate numbers, they trust you more. The CNO must be a credible fiscal advocate for nurses."

And given the hospital's then-bleak financial picture, business as usual was out of the question.

"I knew I had to stop the madness right away, and decided to do it cold turkey," Tuazon said. "In order to eliminate our dependence on nursing agencies, I started doing a lot of things I knew would attract nurses. First of all, I addressed visibility. When nursing leaders are out there working as hard as their staff, nurses know their work is valued and it keeps morale high. Before I came, there was no sense of engagement or commitment among nursing leadership, and I set out to reverse that immediately."

Tuazon wasn't the only member of the hospital's management team addressing visibility.

"Our president and CEO Kevin J. Slavin, FACHE, puts it plainly: 'We are successful because we work hard, and we love what we do,'" he said. "When you see your CEO at 4 a.m. on a Sunday morning on the nursing units, when you have a visible and accessible leader like that, you can't help but excel yourself."

Improvements

Tuazon's professional background provided him with a plethora of effective strategies to improve the nursing environment.

"I've been a nurse for more than 26 years, and one of the best qualifications I give to myself is I'm a Magnet surveyor," he said. "In that role, I've had the great pleasure of visiting 18-19 outstanding hospitals across the country. I know what makes a great professional work environment for nurses, and what it takes to establish and maintain that environment."

Tuazon capitalized on an extensive network of nursing educators and leaders developed in his previous role as president of the New Jersey Board of Nursing to build up the nursing staff at the hospital.

"I made my calls and explained the situation, and soon had six schools of nursing who wanted to affiliate with our hospital," he said. "We started internships to attract and support new graduate nurses interested in joining our organization, implemented externships for junior nursing students to give them an exciting taste of nursing at East Orange General Hospital, and set up nurse residencies for new grads in specialty areas such as critical care."

Tuazon also instituted shared governance, a model that ensures nurses are working hand-in-hand with their leaders toward optimal patient care.

"I realized there had been very little recognition of the good work nurses were doing up to that time, so we went out of our way to highlight accomplishments, and our staff is ecstatic to be recognized," he noted. "We have a nursing performance improvement council and nursing management council that work together to bring the best ideas forward and implement them here."

As the nursing environment excelled, RNs shared the word with colleagues outside the hospital.

"I had one nurse who recruited six other nurses within a 6-month period, with no strings attached," Tuazon noted. "She told them East Orange General Hospital was a good place to work, and they believed her."

Valuing Education

A firm believer in the value of continuing education and professional development, Tuazon redirected some of the money saved from eliminating agency use toward nursing education.

"When I first came, there was only one full-time nurse educator, and I've since hired four more master's-prepared educators, including one who works full-time nights," he said. "Our nurse educators provide support, mentorship and education both in the classroom and on the nursing units. They don't sit in ivory towers in the education department, but are interwoven within the fabric of the nursing department so they're regularly called upon to answer questions. Instead of being the last person called when there's a problem or concern, our nurse educators are there from the very beginning to share their expertise."

While many hospitals struggle to find nurses with advanced degrees, Tuazon went out and located what he needed for his staff.

"What I would suggest to nurse executives who are finding it difficult to hire master's-prepared nurses is that they network with nursing educators," he said. "As busy as we all are, I find time to teach as adjunct faculty at Kean University [Union, NJ] and Monmouth University [West Long Branch, NJ], as well as online through Excelsior College. As I taught graduate courses, students learned about our hospital and our plans for the nursing environment, so I was able to recruit them to join me in that effort."

Education Onsite

Recognizing that nurses often struggle to balance work, home and education, Tuazon went out of his way to bring education to his staff.

"The other thing that excites our staff and promotes retention in our 211-bed urban community hospital with its diverse patient population is that I was able to bring in two schools of nursing to offer onsite RN-to-BSN programs," he said. "We talked about that idea in April 2006, and before you know it, we have our first cohort of BSNs graduating this April from Felician College [Rutherford, NJ]. I chose Felician because of its cohort system, which allows nurses who are disciplined to complete the BSN program in 19 months as part of a group that meets every Tuesday.

"And we affiliated with New Jersey City University [Jersey City, NJ] for an onsite program that allows nurses to take courses when they wish. Some of our staff who can't or don't want to devote a full day each week to classes prefer this model. This fall, we will have a master's program onsite here at the hospital, as well, since many of our BSN nurses want to pursue higher education."

Climbing the Clinical Ladder

A newly launched clinical ladder program, based on educational level, research and other accomplishments, recognizes nurses who go the extra mile.

"Our master's-prepared nurse educators can apply for level IV, the highest level, so their education will be acknowledged and recognized," Tuazon said. "BSN nurses can apply for either level III or level IV, depending on their research interests. Again, we used dollars saved by eliminating agency use to fund this clinical ladder. The money will be paid to our own staff in recognition of their accomplishments, rather than given to agency nurses in the form of bonuses and other carrots."

Two and a half years after he arrived at East Orange General Hospital, Tuazon leads a very different nursing department.

"We no longer use agency nurses, and because we've been able to weather the storm, our bottom line has been in the black, and we're expanding services," he said. "With a vacancy rate of less than 5 percent, I can pick the best nurses who apply from area hospitals and I am even in a position to over-hire so I can have replacements in line for the future needs of the hospital."

Sandy Keefe is a frequent contributor to ADVANCE.

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